Sleep Quiz Two or more checked categories indicates high likelihood of sleep apnea. Please tell us how would you like us to respond to your question and/or comments?: Phone Email I prefer not to be contacted Name: (required) Email: (required) Address: City, State, Zip Code: Phone: (required) Date: Height: Weight: Age: Neck Size: Gender: Male Female Has your weight changed?: Yes No Do you snore?: Yes No If you snore: How would you describe your snoring?: Slightly louder than breathing Louder than talking As loud as talking Very Loud How often do you snore?: Almost everyday 3-4 times a week 1-2 times a week Never or almost never Does your snoring bother other people?: Yes No Has anyone noticed that you quit breathing during your sleep?: Almost everyday 3-4 times a week 1-2 times a week Never or almost never Are you tired after sleeping?: Almost everyday 3-4 times a week 1-2 times a week Never or almost never Are you tired during waketime?: Almost everyday 3-4 times a week 1-2 times a week Never or almost never Have you ever nodded off or fallen asleep while driving?: yes No If yes: How often does this occur?: Almost everyday 3-4 times a week 1-2 times a week 1-2 times a month Never or almost never Do you have high blood pressure?: Yes No Not Sure Make a Payment or Apply for Care Credit Patient Bill of Rights Prepare for Sleep Study Privacy Practices Resources Sleep Quiz We provide full-service care from diagnosis to treatment. Call us today to learn more about this program and how we can help. CALL US TO LEARN MORE 877-595-1090 Referring Providers- We are now part of Michigan Health Connect! If you are a member, please use your Michigan Health Connect account to refer to us quickly and safely! For more information, see http://michiganhealthconnect.org/ his is the fastest growing referral source in Michigan!